ANNEXURE ‘I’

AFFIDAVIT

I, Ashok Kumar Bhageria S/O Lt. Purusottam Lal Bhageria, residing at

Village - Khairabari, P.S.- Barpeta Road, District – Barpeta, Assam - 781315 Date of
Birth – 24-12-1960, being an applicant for issue of passport, do hereby solemnly affirm
and state as follows :

1. That the names of my parents and spouse are as follows:

(i) Father : Lt. Purusottam Lal Bhageria
(ii) Mother : Lt. Ginni Devi Bhageria
(iii) Spouse : Smt. Babita Devi Bhageria

2. That I am continuously resident at the above mentioned address since my birth.

3. That I am citizen of India by birth and that I have neither acquired the citizenship
of another country nor have surrendered or been terminated /deprived of my
citizenship of India.

4. That I have not, at any time during the period of five years immediately preceding
the date of this affidavit, been convicted by any court in India for any offence
involving moral turpitude and sentenced in respect thereof to imprisonment for not
less than two years.

5. That no proceedings in respect of any criminal offence alleged to have been

committed by me are pending before any criminal court in India.

Contd. (2)
 (2)

6. That no warrant or summons for any appearance, and no warrant for any arrest,
has been issued by a court under any law for the time being in force, and that my
departure from India has not been prohibited by order of any such court.

7. That I have never been repatriated from abroad back to India at the expenses of
Govt. of India / I was repatriated from abroad back to India at the expenses of
Govt. of India but reimbursed expenditure incurred in connection with such
repatriation.

8. That I will not engage outside India in activities prejudicial to the sovereignty and
integrity of India.

9. That my departure from India will not be detrimental to the security of India.

10. That my presence outside India will not prejudice the friendly relations of India
with any foreign country.

Place : Barpeta
Date: -12-2015 DEPONENT
VERIFICATION

Verified on day of December, 2015 at Barpeta, that the contents of the above
mentioned affidavit are true and correct and nothing material has been concealed.

DEPONENT